Citation NR: 9633821
Decision Date: 11/29/96 Archive Date: 12/04/96
DOCKET NO. 94-27 291 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Columbia,
South Carolina
THE ISSUES
1. Entitlement to service connection for anemia.
2. Entitlement to service connection for arthritis of the
elbows.
3. Entitlement to service connection for diabetes mellitus
with neuropathy.
4. Entitlement to service connection for an acquired
psychiatric disorder to include post-traumatic stress
disorder (PTSD).
5. Entitlement to special monthly pension on account of the
need for regular aid and attendance or on account of being
housebound.
REPRESENTATION
Appellant represented by: Disabled American Veterans
ATTORNEY FOR THE BOARD
A. A. Booher, Counsel
INTRODUCTION
The veteran had active service from July 1967 to March 1969.
This appeal is brought to the Board of Veterans’ Appeals (the
Board) from rating actions by the Department of Veterans
Affairs (VA) Regional Office (RO) in Columbia, South
Carolina. The veteran is in receipt of nonservice-connected
pension benefits; due to uncertainty as to what possibly
pertinent evidence may be otherwise obtained, consideration
by the Board of the issue of entitlement to special monthly
pension benefits will be deferred pending completion of the
development on the other issues.
REMAND
For reasons which will be discussed further below, the Board
finds that development is required with regard much of the
evidence and in association with several of the veteran’s
claims. A remand would not ordinarily require any
significant delineation of the evidence. However, to better
assist the RO and the veteran in understanding what is needed
versus what may be available, the Board will make an
exception in this case.
Current Evidence of record: Service
The veteran’s service records show that he was trained as an
aircraft maintenance crewman, and specifically was trained to
work on the UH-1D helicopter. He was in Vietnam for almost
one year and participated in the Tet Counter Offensive,
earning the Vietnam Service Medal, the Republic of Vietnam
Commendation Medal with device 60, and 1st and 2nd overseas
bars. He earned a badge with rifle bar on the M-14 and the
M-16. It appears that he was primarily assigned to the 56th
Transportation Company (ADS) while in Vietnam. On one or
more occasions soon after separation from service, an attempt
was made to obtain additional service records without
success. Available service records are limited but show some
evidence of right and left foot and back complaints, and
nervousness. At the time of the latter assessment, he said
that at age 18, he had had a bicycle accident and became so
nervous he had required a month in a mental institution. It
was also noted that he had been trained as a mechanic but
that he had become so frightened of flying that he now worked
in the motorpool. Although his service records otherwise
describe him as having completed 6 years of elementary
school, at the time of psychiatric evaluation in 1968, he
said he had failed the 1st, 4th, 5th and 6th grades and his
high school equivalency test.
Current Evidence of record: Post-service
At the time of his initial claim for benefits (relating to a
right foot injury) immediately after separation from service,
the veteran reported that he had been seen by Dr. W. E.
Bryant of Hemingway, S.C. since March 11, 1969.
A few isolated outpatient records are in the file showing
that the veteran was seen at the VA facility in Charleston,
S.C., in 1969, right after separation from service. Complete
records have not been sought or obtained in that regard. He
was also examined by the VA in Columbia, S.C., in January
1970 when the primary assessment was limited to idiopathic
mental deficiency. He was admitted to a VA hospital in
Columbia in September 1973 stating that his illness had
started in 1969 when he had progressive weakness and lack of
energy. He said he had been admitted twice to the Charleston
VAH, once in 1970 and again in March 1973, and was found to
have severe anemia. He also became peculiar, uncooperative
and paranoid, and the examiner suggested he might be
exhibiting psychotic behavior, possible schizophrenic
reaction, paranoid type; he signed out against medical advise
before assessments could be undertaken. Except for the few
outpatient records and the summary of the 1973
hospitalization, no VA records from 1969 to 1973 are in the
file.
On a VA examination in 1974, it was noted by the examiner
that the veteran had apparently had severe anemia of
undetermined etiology since 1969, for which he had taken
medication from his private physician (possibly Dr. Bryant),
and that he had been hospitalized on several occasions since
service by the VA, but had left because he was uncomfortable
with the confinement. He was also found to have splenomegaly
and a history of psychotic behavior. He said he had been
hospitalized at the South Carolina State Hospital at age 17.
However, the psychiatrist noted that an accurate assessment
of his mental health could not be made as an outpatient, and
that hospitalization was also needed to determine the cause
of the anemia. It is unclear whether any such
hospitalization was undertaken, in which case, the records
are not in the file. A VA Form 10-7131 notes that he was
seen as an outpatient at the Columbia VAH for anemia in May
1977 for which records are also not in the file.
Some clinical records and reports are in the file relating to
the Social Security Administration (SSA) award. Included is
a statement from F. Baker, M.D., signed in June 1974,
referring to care by Dr. Bryant for the first time in 1964
and again in 1969 for an employment examination; he again saw
him in 1969 when he was “extremely nervous” after being in
Vietnam, and in 1972 and 1973 with severe anemia. Records
are not in the file from Dr. Bryant. Another physician, E.
O’Bryan, Jr., M.D., who evaluated him in 1974, said that the
veteran had said that he had been told that he had anemia
when discharged from service in 1969. Diagnoses were
possible abnormal paranoid behavior and anemia - etiology to
be determined.
One physician, E. Camp, M.D., stated in 1974 that the veteran
was essentially housebound. The diagnosis was chronic
paranoid psychosis. The veteran has said that he had been
admitted to South Carolina State Hospital in 1964-1965 at
sometime between ages 16 and 19; he was unsure exactly when.
Another physician, J. Hooper, IV, M.D., in 1983, diagnosed
“probable traumatic war neurosis, questionable chronic
paranoid, questionable depression”, but said that a more
exact diagnosis was not possible without more than a single
examination.
An examination in March 1993 at a VA facility, reported on a
VA Form 21-2680, noted numerous problems including chronic
PTSD from Vietnam, with unemployability and virtual isolation
from the community. Physically, he had some low back pain,
but a complete physical examination as to other disabilities
was not undertaken. The examiner described him as being
virtually hermit-like and refusing to go outside the VA
apartments without others.
A VA clinical examination in April 1993 apparently relied on
history which does not appear to be entirely consistent with
the evidence of record. The veteran said his feet had been
numb since 1970. The physician diagnosed obesity, diabetes
mellitus, degenerative disease of the elbows and “inadequate
personality”. However, a psychiatric examiner, who acquired
an extensive history, diagnosed PTSD. The available recent
VA outpatient records diagnosed PTSD. However, it is not
shown that the veteran has ever been afforded a comprehensive
psychiatric evaluation to include PTSD.
The veteran has given an extensive description of his service
experiences both at the time of a VA psychiatric examination
in 1993, and in a 10 page VA Form 21-4138, dated in April
1993. The RO endeavored to obtain verification of stressors
from the U.S. Army and Joint Services Environmental Support
Group (ESG), and to a limited degree, that was accomplished.
In fact, a report in April 1994 by ESG, to some extent,
verified the veteran’s allegations. However, instead of
submitting the documents on which the veteran described his
experiences, the RO had summarized them as relating to flying
on missions, guard duty, etc. Not all such incidents
recalled by the veteran were mentioned. The ESG sought
additional information which was apparently not submitted.
Assessment
It is clear from the evidence cited above that extensive
evidence is not now of record. Given the circumstances of
this case, and the obligations imposed upon the VA by both
regulations and judicial guidelines, the Board finds that it
is appropriate to endeavor to obtain as much evidence as
possible with regard the veteran’s pending claims.
It will also be noted that included in certain records
primarily relating to psychiatric problems are references to
anemia. Moreover, it is noted that the veteran’s claims for
anemia, diabetes mellitus and arthritis have not been fully
addressed by the RO as they relate to presumptive service
connection. It is argued that these problems were present
shortly before separation from service and/or just after
separation from service, and that he was treated for at least
anemia and diabetes during that time, a period of time for
which currently available clinical records are limited. The
evidence tends to show fatigue and irritability soon after
service, but clinical evidence of blood work and other
studies which would be relevant to a more credible
determination in that regard are not in the file.
There is also evidence in the file of a differential
diagnosis of psychosis, although that has not been fully
addressed by the RO with regard possible service connection
for a psychiatric disability. Service connection was denied
by the RO for PTSD although the veteran has not undergone
specialized evaluation to determine the presence or efficacy
of such a diagnosis.
A private physician has determined that the veteran is
housebound. The RO determined that the veteran is not
housebound. It is unclear upon what basis that determination
was made. In any case, the Board is unable to substitute its
own judgment for that of a medical expert. Colvin v.
Derwinski, 1 Vet.App. 171, 175 (1991).
Based on the evidence of record, the Board finds that
additional development is required. The case is REMANDED for
the following actions:
1. The RO should request that the
service department provide all service
personnel, medical and other records, and
these should be attached to the claims
folder.
2. The RO should obtain complete VA
outpatient and inpatient treatment
records from separation from service
since 1969 to present, including from the
VA facilities in Charleston and Columbia,
and these should be added to the claims
folder.
3. The veteran should be asked to
clarify, with the assistance of family
members if possible, more exact details
including locations and dates of his pre-
service treatment and hospitalizations,
as well as all private care post service,
particularly in the years from 1969 to
1973. After appropriate release, the RO
should acquire complete clinical records
from all pre-service and post-service
care and evaluations, including but not
limited to Dr. Bryant in Hemingway, S.C.,
and the South Carolina State Hospital,
and to include psychiatric evaluations,
X-rays of joints, as well as blood and
urinalysis studies, if available. These
should then be added to the claims
folder.
4. The RO should then provide complete
copies of all documents in which the
veteran identifies his alleged in-service
stressors (i.e., the VA psychiatric
examination in 1993, and the associated
10 page VA form in 1993), as well as
copies of all pertinent service documents
now in the file to the ESG for
verification of stressors. The veteran
should be also requested to address the
specific inquiries and suggested
clarifications provided by the ESG in
their letter of 1994, and if he is able
to do so, the ESG should be given that
information as well.
5. The veteran should then be
hospitalized by the VA for a period of
observation and evaluation to determine
the exact nature and status of all his
disabilities, the etiology thereof, and
accurate and comprehensive description
and diagnosis relating to his anemia,
arthritis, diabetes mellitus, and all
psychiatric disorders. The examiners
should be provided with the claims
folder, as well as all evidence obtained
pursuant to this REMAND. All necessary
laboratory and other tests should be
accomplished, including with regard PTSD.
6. After completion of the above, the
case should be reviewed by the RO with
regard to all issues in appellate status.
If the decision remains unsatisfactory, a
Supplemental Statement of the Case should
be issued to include all pertinent
regulations and evidence, and the veteran
and his representative should be given
the requisite opportunity to respond.
The case should then be returned to the Board for further
appellate review. The veteran need do nothing further until
so notified.
D. C. SPICKLER
Member, Board of Veterans' Appeals
The Board of Veterans' Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741
(1994), permits a proceeding instituted before the Board to
be assigned to an individual member of the Board for a
determination. This proceeding has been assigned to an
individual member of the Board.
Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the
Board of Veterans' Appeals is appealable to the United States
Court of Veterans Appeals. This remand is in the nature of a
preliminary order and does not constitute a decision of the
Board on the merits of your appeal. 38 C.F.R. § 20.1100(b)
(1995).
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